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Stele of California-Health and Welfare Agency • <br /> Department of Hez th Services <br /> HAZARDOUS MATERIALS All applicable items 1. HML No . Page <br /> SAMPLE ANALYSIS REQUEST must be completed To rC 0.1 �CC, 2 1 °' / <br /> 3. Collector/Address 4. Phone <br /> JoScf/-/ /9 F2i9N7 f9/G) 73`i-34Xv 5. Priority <br /> yy/Zl Pv4,2rX TNN /_Z7) SLC 7Z) C/5, a. Authorized by <br /> 6. Date Sampled /a 0'7/8/1 7. Time Sampled /s aS)Hours 8. Codes (fill in all applicable codes) <br /> 9. Activity X Ent ❑ Sury ❑ Site Mit ❑ Permitting ❑ Ait Tech ❑ Other a. STC L9 O 3 O 9 O <br /> b. Region <br /> 10. SAMPLING LOCATION N O 0 A J1/ D c. TPC <br /> a. EPA ID No. <br /> b. Site d. INDEX a y O <br /> J/ e. PCA q10 d O <br /> c. Address 4 2 7 rn yJ J7�Q 1. SITE <br /> Number Street City Zip <br /> g. County D 3 c/ <br /> 11.SAMPLES <br /> � Container <br /> a. Ip b.Collector's No. c.HML No. d. Type e.Type L Size g. Field Information <br /> T— So, I _G1 <br /> T— 11 IZo7 cr�3 D L___�__ �_ K <br /> (T° JF l�7 Dori 5 u _ F <br /> L�e. ( '�— <br /> IG12o7 -eviC . �j u2 so, 1 —L E <br /> F, C <br /> G. <br /> L <br /> H. D <br /> 12.ANALYSIS REQUESTED I. El PCB k.❑ Ext. <br /> (Screeneng) <br /> a. IR pH C ` ` g. ❑ VOA L ❑Chlorinated <br /> Metal <br /> Pesticides <br /> m <br /> —� <br /> Scan h. 0 PAH ❑Organo-P <br /> Pesticides <br /> C. x Metals <br /> ISpec) ,ft b'i �� ,/� F F i. ❑ Phenols n, ❑ <br /> d. ❑ W.E.T. I ❑ <br /> mates o.❑ <br /> 13. CH OF CUSTODY,,-) ��ffOi�" �ie/9/✓'7 <br /> a. � .,,.�,r 1 �.G z - <br /> O 7 SE - S/ bu <br /> Sig rya ee Na a/Title /CInclusive Dates <br /> b. <br /> 'gn u e <br /> Na Inclusive Dates <br /> cTit e <br /> Signalure Namerritle Inclusive Dates <br /> d. <br /> Signature Name/Title Inclusive Dales <br /> 14. SPECIAL REMARKS <br /> 15. RECEIVED BY a. Title o ( <br /> `� � b. Date �� -� <br /> S <br /> 16. SAMPLE ALLOCATION a.J.HML-Berkeley b. ❑ HML-SC c. ❑ AIHL d. ❑ Contract b. Date <br /> 17. ANALYSIS REQUESTED a [�--QA,- �\fie L <br /> A <br /> B <br />